Training anesthesiologists in out-of-operating room anesthesia.

PURPOSE OF REVIEW: The purpose of this review is to describe recent developments and current trends in training anesthesiologists in out-of-operating room anesthesia (OORA). RECENT FINDINGS: In the United States, the Accreditation Council for Graduate Medical Education recently updated its training requirements to include a mandatory 2-week rotation in OORA for anesthesiology residents. This likely reflects the continuing expansion of anesthesia services in the out-of-operating room (OOR) environment as well as the increasing complexity of OOR procedures and medical acuity of patients in these settings. In the United Kingdom, the Royal College of Anaesthetists has rigorous and progressively complex requirements for trainees in 'non-theater' anesthesia experience as they move through the four stages of training. A variety of educational strategies and a well-validated six-step process for curriculum development are described in this review. SUMMARY: This review will provide useful models for training directors needing to design and implement OOR rotations for their trainees.

Systematic Postoperative Nausea Prophylaxis Feedback Improves Clinical Performance in Anesthesiology Residents.

BACKGROUND: Electronic medical records can generate a wealth of information regarding compliance with perioperative clinical guidelines as well as patient outcomes. Utilizing this information to provide resident physicians with measures of their own clinical performance may positively impact residents' clinical performance. We hypothesize that providing residents with objective measures of their individual adherence to evidence based postoperative nausea and vomiting (PONV) management protocols will improve their compliance with standardized treatment methods. METHODS: We conducted a retrospective baseline analysis of junior anesthesiology residents' compliance with PONV prophylaxis guidelines for high-risk patients. This was followed by a prospective cohort study, before and after an educational intervention, a 15 minute lecture on PONV prophylaxis. The number of pharmacologic prophylactic interventions were tabulated for each operative case and reported back to individual residents in blind and anonymous fashion. The primary outcome was the use of two or more prophylactic interventions for a high-risk patient, while the secondary outcome was the use of three or more prophylactic interventions. A follow up survey was administered to participating residents regarding the use of their individualized clinical performance. RESULTS: After implementation of feedback, patients received a significantly higher amount of PONV prophylactic treatments (p=0.001, means of 1.35 vs. 1.99). Comparison of percentage compliance was 38% vs 73%, respectively (p<0.001). In a follow up survey, residents received the feedback intervention well and had no significant concern in the dissemination of deidentified performance outcomes publically. CONCLUSIONS: Resident compliance with PONV treatment guidelines was improved merely by auditing performance and providing individualized feedback. High-risk patients appear to receive more prophylactic agents after performance feedback and may be more effective than a more commonly used educational intervention to address the same topic. Providing direct performance feedback may be a useful tool for integration into graduate medical education programs.

Resident Perceptions and Cost Analysis of a Virtual Patient Application for Anesthesia-Related Critical Incidents.

BACKGROUND: Since there are limitations on the amount of time residents can spend in full-scale simulation sessions, we introduced a virtual patient application into our anesthesiology program to su pplement mannequin-based simulation sessions. Previous investigations have demonstrated a positive educational effect for virtual patients, but suggest that further research is needed to clarify how to effectively implement virtual patients in medical education. We present a description of the implementation of a virtual patient application in our residency training program, the residents' evaluation of their experience with the application, and a cost analysis of incorporation of the application into the residency program, in order to determine the residents' perceptions of the value and estimate the cost of using virtual patients in anesthesia residency training. MATERIALS AND METHODS: For 20 years all anesthesia residents in our training program have been required to complete ten simulated cases using a virtual patient application prior to the end of their CA-1 year. Residents are given access to the anesthesia virtual patient application on departmental computers and also on their own personal computers. Residents complete 10 required cases on their own or in pairs and send printed case logs to an anesthesia attending for review and feedback. Participants anonymously completed surveys rating their perceptions of the virtual patient application's effectiveness. Cost to implement this program was estimated retrospectively. RESULTS: In total, 404 residents completed 3593 virtual patient cases in approximately 2800 hours. RESIDENT PERCEPTIONS: 252 residents completed the anonymous survey (62%). Almost all the respondents (97%) rated the virtual patient curriculum as worthwhile; 88% rated the application to be realistic; 97% felt better prepared to handle anesthesia-related critical incidents; 87% stated they had at least one event in a real operating room similar to an emergency presented in the virtual patient application, and 40% stated they experienced more than one such event. 93% were stimulated to read about management of anesthesia-related critical incidents after using the application. COST-ANALYSIS: The estimated cost to implement the screen-based curriculum for 20 years was $44,000 including the cost of software and faculty time. Therefore the cost for the 2800 hours of virtual patient simulation was about $16 per hour. CONCLUSIONS: The anesthesia virtual patient application was easily incorporated into our residency training program at the University of Washington. The application was well-received by anesthesia residents, helped them feel more prepared to manage critical incidents, and stimulated them to read more concerning the management of anesthesia-related critical incidents. The virtual patient application is far less expensive than mannequin-based simulation and much more available. Therefore, virtual patients should be considered an easily accessible supplement to mannequin-based simulation training.

The disclosure of unanticipated outcomes of care and medical errors: what does this mean for anesthesiologists?

The disclosure of unanticipated outcomes to patients, including medical errors, has received considerable attention of late. The discipline of anesthesiology is a leader in patient safety, and as the doctrine of full disclosure gains momentum, anesthesiologists must become acquainted with these philosophies and practices. Effective disclosure can improve doctor-patient relations, facilitate better understanding of systems, and potentially decrease medical malpractice costs. However, many physicians remain wary of discussing errors with patients due to concern about litigation, the communication challenges of disclosure, and loss of self-esteem. As a result, harmful errors are often not disclosed to patients. Disclosure poses special challenges for anesthesiologists. There is often very limited time before the anesthetic in which to build the patient-physician relationship, and anesthesiologists usually function within complex health care teams. Other team members such as the surgeon may have different perspectives on what the patient should be told about operating room errors. The anesthesiologist may still be physically caring for the patient while the surgeon has the initial discussion with the family about the event. As a result the anesthesiologist may be excluded from the planning or conduct of the important initial disclosure conversations. New disclosure strategies are needed to engage anesthesiologists as active participants in the disclosure of unanticipated outcomes. Anesthesiologists should be aware of the emerging best practices surrounding disclosure, as well as the training opportunities and disclosure support resources that are increasingly available. Innovative models should be developed that promote collaboration between all perioperative team members in the disclosure process. There are important opportunities for anesthesiologists to play a leading role in defining specialty-specific disclosure practices and to more effectively meet patients' needs for disclosure after unanticipated outcomes and medical errors.

Dexmedetomidine sedation for laryngeal framework surgery.

OBJECTIVES: Sedation for laryngeal framework surgery has lacked easy modulation between appropriate pain control, airway protection, and the alertness appropriate for vocal testing. Our objective was to determine whether dexmedetomidine hydrochloride could safely and effectively be used as the sole intravenous anesthetic agent in conjunction with local anesthesia for laryngeal framework procedures. METHODS: We undertook a prospective review of 14 patients who underwent laryngeal framework surgery with dexmedetomidine anesthesia in 2004 and 2005. All dexmedetomidine doses, sedation levels, and vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation level, were recorded every 15 minutes by the anesthesiologist throughout the duration of the procedures. Operative conditions were noted by the surgeon, focusing special attention on airway protection, patient arousability, and patient comfort. RESULTS: Dexmedetomidine sedation produced hemodynamic and respiratory values that were maintained near preoperative values, and overall pharyngeal-laryngeal integrity provided superior operating conditions for the patient and the operating surgeon. CONCLUSIONS: We believe that dexmedetomidine provides excellent sedative and operative conditions for awake laryngeal framework procedures. Coupled with local anesthesia, dexmedetomidine produced virtually no undesirable hemodynamic or respiratory effects, while allowing for adequate sedation the majority of the time. The operative conditions were markedly improved over those of previous standard monitored anesthesia regimens.

Hemodynamic changes in visceral organs following closed head trauma in rats.

BACKGROUND: Gastrointestinal (GI) tract dysfunction is well documented following head injury. Our study sought to determine whether head injury causes an immediate impairment of the splanchnic circulation which may contribute to later GI sequelae. METHODS: Three groups of eight rats each received either no closed head trauma (CHT) (group 1) or CHT (groups 2 and 3) immediately following baseline measurements at time 0. The primary measures of interest - individual organ blood flows and cardiac output (radioactive microspheres), and individual organ and systemic vascular resistances - were determined in the control group, at 5 min after CHT in group 2, and at 15 min after CHT in group 3. RESULTS: CHT caused no significant change in portal venous inflow (flows were 2.40+/-0.36, 2.38+/-0.54, and 2.33+/-0.62 ml min(-1) 100g(-1)bw, mean+/-S.D., in groups 1, 2, and 3, respectively). Individual organ and total hepatic blood flow, cardiac index, splanchnic, portal, and total peripheral resistance, and mean arterial or portal venous pressure also did not differ significantly among groups. CONCLUSION: We found no significant changes in splanchnic circulation immediately after CHT in this rat model. Our results do not support the hypothesis that the splanchnic circulation is impaired immediately after head injury and that splanchnic blood flow impairment immediately after head injury may contribute to post-head injury GI dysfunction.

Intubation risk factors for temporomandibular joint/facial pain.

Endotracheal intubation has been proposed as a risk factor for temporomandibular joint dysfunction (TMD) in a limited number of published case reports and systematic studies. Symptoms may result from forces applied with the laryngoscope, or manually in an attempt to complete the intubation, and may be related to the duration in which temporomandibular joint (TMJ) structures are stressed. The objective of this study was to examine risk factors for TMD complaints associated with endotracheal intubation. One hundred twenty-two patients who underwent endotracheal intubation for surgery at the University of Washington Medical Center participated. Exclusions included surgery of the head or neck, cognitive deficit, or emergency surgery. Subjects were assessed presurgically, and at 7 and 14 days postoperatively. Gender, interincisal distance, and age were found to be significantly associated with TMD symptoms lasting as long as 14 days following intubation. For both TMD pain and TMD nonpain symptoms, the most reliable predictor of a complaint following intubation was a history of TMD complaints within a year preoperatively. Any association between endotracheal intubation and the development of short-term TMD symptoms is likely to be found in patients with prior report of such conditions, and we therefore recommend a review of TMD complaint history when planning general anesthesia.

Dexmedetomidine sedation during awake craniotomy for seizure resection: effects on electrocorticography.

Patients with refractory seizures may undergo awake craniotomy and cortical resection of the seizure area, using intraoperative functional mapping and electrocorticography (ECoG). We used dexmedetomidine in 6 patients, transitioning successively from the asleep-awake-asleep method, through a combined propofol/dexmedetomidine sedative infusion, to dexmedetomidine as the only sedation. Initial experience with the asleep-awake-asleep method in 2 patients was successful with the replacement of propofol/laryngeal mask anesthesia, 20 to 30 minutes before ECoG testing, by dexmedetomidine infusion, maintained at 0.2 mcg kg-1 h-1 throughout neurocognitive testing. Propofol anesthesia was reintroduced for resection. One patient received combined dexmedetomidine (0.2 mcg kg-1 h-1) and propofol (200 mcg kg-1 min-1) infusions for sedation. Both infusions were stopped 15 minutes before ECoG. Subsequently, they were restarted and the epileptic foci resected. Three patients received dexmedetomidine as the sole sedative agent, together with scalp block local anesthesia, and incremental boluses totaling 150 to 175 mcg of fentanyl per case. Dexmedetomidine was started with 0.3 mcg kg-1 boluses and maintained with 0.2 to 0.7 mcg kg-1 h-1for craniotomy, testing, and resection. The infusion was paused for 20 minutes in 1 patient to allow improvement in neurocognitive testing. This occurred within 10 minutes. All patients enjoyed good hemodynamic control, with blood pressure maintained within 20% of initial values, and made uneventful recoveries. The surgical conditions were all reported as favorable. Dexmedetomidine can be used singly for sedation in awake craniotomy requiring ECoG. Individual dose ranges vary, but a bolus of 0.3 mcg kg-1 with an infusion of 0.2 mcg kg-1 min-1 is a good starting point, allowing accurate mapping of epileptic foci and subsequent resection.

Effects of bispectral index monitoring on recovery from surgical anesthesia in 1,580 inpatients from an academic medical center.

BACKGROUND: The purpose of this study was to determine whether monitoring Bispectral Index (BIS) would affect recovery parameters in patients undergoing inpatient surgery. METHODS: Anesthesia providers (n = 69) were randomly assigned to one of two groups, a BIS or non-BIS control group. A randomized crossover design was used, with reassignment at monthly intervals for 7 months. Duration of time in the postanesthesia care unit, time from the end of surgery to leaving the operating room, and incidence of delayed recovery (> 50 min in recovery) were compared in patients treated intraoperatively with or without BIS monitoring. Data were analyzed by analysis of variance, unpaired t test, or chi-square test as appropriate. RESULTS: One thousand five hundred eighty patients in an academic medical center were studied. The mean BIS in the monitored group was 47. No differences were found in recovery parameters between the BIS-monitored group and the control group when comparisons were made using all subjects or when data were analyzed within anesthetic subgroups stratified by anesthetic agent or duration of anesthesia. There were some small reductions in the intraoperative concentration of sevoflurane (but not isoflurane). CONCLUSIONS: The use of BIS monitoring for inpatients undergoing a wide variety of surgical procedures in an academic medical center had some minor effects on intraoperative anesthetic use but had no impact on recovery parameters.

Continuous intrathecal meperidine for severe refractory cancer pain: a case report.

The control of severe cancer pain may be problematic despite advances in pain management. Patients with severe intractable pain and/or intractable side effects may require aggressive interventional pain management strategies including the administration of medications by the continuous intrathecal route and/or neurosurgical procedures. Various medications, including opioids, local anesthetics, and alpha-2 agonists may be used intrathecally for the control of cancer pain. Failure of the intrathecal route may require the additional use of neurosurgical procedures such as cordotomy for pain control. We describe a case of severe cancer pain refractory to conventional intrathecal medications and cordotomy that was successfully managed by the addition of meperidine to the intrathecal regimen.

Systems-Based Practice and Anesthesiology Residency: Report from the SEA Task Force on the ACGME Core Competencies.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires that residents be educated in six general core competencies, but has relied on individual specialties to develop their own definitions, teaching methods and evaluative tools. The Society for Education in Anesthesia took the initiative by organizing a two-day conference to accomplish these goals. METHODS: Facilitated by four anesthesia educators, anesthesiologists from diverse programs and backgrounds employed open systems theory to better define System-Based Practice and outline key examples specific for anesthesiology. RESULTS: Pre-operative assessment, intraoperative management, inter-disciplinary pain management team, and healthcare facility interactions were selected as forums where observable activities, educational goals and practical assessment tools universal enough to be applicable to most anesthesiology training programs can be developed. CONCLUSIONS: The application of open systems theory in the setting of small focus groups proved successful by producing definitions, teaching methods and evaluative tools for SBP. The diversity of the groups should allow the products to have flexibility and widespread use.